SACRAMENTO—A pilot for a national airline sought much-needed elbow surgery for more than a year, and received authorization from her Workers’ Compensation insurer only after complaining to a senior airline official that she had problems lowering landing gear and was endangering hundreds of passengers, one California physician reports.

Authorizations for physical therapy or imaging may take six months or more, reports another physician, and still another reports that authorizations for needed surgery take up to a year.

Sums up one physician: “Our group will no longer see workers’ comp. It is a terrible system. It’s fraud.”

These are real stories from the front lines on the Workers’ Compensation battlefield. They come from physicians who have treated workers under reforms, effective in 2004, that were supposed to cut costs without harming patients or reducing care. The California Medical Association surveyed its membership this year to gauge how these reforms are working. CMA began compiling those responses this summer and they are issued now in the final report: “Hostile to Physicians, Harmful to Patients: The Workers’ Compensation …Reform?”

More than 250 physicians contributed to the report, relaying their experiences with how insurers and the Division of Workers’ Compensation are carrying out the new law. Physician experiences are mostly negative, with 63% saying they intend to leave or reduce participation in the program despite these reforms. Of these, a third said they would quit entirely, raising questions as to who will treat workers injured on the job.

“Doctors treating injured workers are locked in a system that is hostile to physicians and often harmful to the patients they serve,” said Dr. Jack Lewin, CEO of the CMA. “Utilization reviews are so cumbersome and misused that patients are not getting the treatment they obviously need. The bottom line is that law is not being followed, and we not only worry that the reforms are endangered, but we worry that the health of working Californians is at risk.”

In releasing the report, CMA officials emphasized that premium reductions from the reforms are a vital and important achievement. But they noted that carriers and the Division of Workers’ Compensation are not paying sufficient attention to quality of care. The DWC and Governor Arnold Schwarzenegger should look critically at why the reforms have failed to achieve the ultimate goal of getting injured workers back on the job. “The issue of getting the reforms right is important because any gains from the new law will not be sustainable if they are not accompanied by real improvements in how care is delivered to injured workers,” said Dr. Lewin.

Based on the survey, the CMA concludes that access to care for workers is doubly in jeopardy – first, because needed care is being denied, and second, because physicians will quit the program rather than face persistent, unnecessary hassles and second-guessing in obtaining appropriate care for injured workers.

The CMA, as an employer itself and representing thousands of physician employers, believes reforms are necessary, but CMA physicians are troubled by the lack of auditing and enforcement by the Division of Workers’ Compensation. The result is that insurers and employers operate outside the law. The CMA is asking for a reexamination of their UR regulations, a strict audit program and aggressive enforcement through substantial penalties for non-compliance. In addition, the agency should end medical decision-making by non-physicians and out-of-state physicians outside the reach of California law The CMA is also seeking strict enforcement of deadlines that speed patient care, as well as streamlining a system that currently results in lost and delayed claims, treatment and payment.

The state workers’ compensation statutes, for example, call for timely review of treatment decisions using evidence-based, peer-reviewed, nationally recognized guidelines — applied by individuals with the proper experience to interpret them — and respond within 14 days. The law also requires documentation to support any modification, delay or denial. However, under penalties proposed by the Division for Workers’ Compensation, an employer or insurer who failed to comply would be fined less than it would cost to provide the care mandated under law.

Frustrated physicians report that requests for treatment authorizations are not being made within the 14 days required by law, leaving injured patients without timely treatment and often in pain. “Surgeries were just ignored and required repetitive requests to obtain authorizations,” said a Santa Clara physician. Furthermore, although the laws call for prompt payment, physicians reported that payments are delayed on average a month beyond the legal maximum time of 45 working days.

One of the greatest difficulties revealed in the survey was the inability to simply talk to a reviewer who could authorize treatment. In all, 99% of the surveyed physicians said they had difficulty reaching a reviewer, with two thirds indicating that had to call back many times to find one at all. The result is that patients go months without any treatment. “Patient never received any form of treatment, but carrier is requesting patient to return to work or settle …yet they never realized the patient never was treated because all requests were denied or delayed.” –Santa Barbara physician.

Physicians contend with other egregious problems in providing care to injured workers, reporting that reviewers second-guessed their own review staff, limited care based on the age of the worker, applied poor clinical judgment, and even imposed risk on others due to failure to approve treatment when critical physical function was impaired, such as was the case with the commercial pilot.

Finally, the physicians reported insurer misuse of guidelines developed by the American College of Occupational and Environmental Medicine (ACOEM), in citing the guidelines improperly as a basis for denying care. The ACOEM Guidelines were developed by environmental and occupational medicine physicians to be used by treating physicians as guidelines for medical treatment. They are not intended as a cookbook formula for treatment of an injury to be applied by a reviewer without relevant medical expertise and experience. And they are not written for use by non-physicians. It is not surprising then that a substantial proportion of denials are overturned on appeal (43% responded that at least one in four of every denial is overturned). This would suggest that numerous workers are refused care unnecessarily, leaving patients in pain and without appropriate treatment for months. Physicians in the CMA survey gave examples of reviewers who are not physicians or who are not licensed in California. Some reported speaking to reviewers who needed to meet a “denial” quota.

“One other daily, and I mean daily bad experience, is to have a supposed Utilization Review M.D. in another state deny any aspect of evaluation and/or treatment for a patient that I have examined at the request of the industrial carrier. Frequently, that supposed M.D. is not in the same specialty and has no idea of what the special tests or treatment is supposed to accomplish.” –Los Angeles County physician.

Unnecessary work is required to obtain authorization for treatment, to appeal denials, and to repeatedly bill for treatment not paid at all or on time. This adds extra costs that make the program often too costly for a physician’s office. “Collecting for treatment for WC has become an incredible nightmare,” reported a Sacramento physician. “We are treating a lot of patients essentially for free right now.”